Applying epidemiologic concepts of primary, secondary, and tertiary prevention to the elimination of racial disparities in asthma

Despite medical and scientific advances, racial and ethnic disparities persist in US asthma morbidity and mortality rates. Progress in the elimination of these disparities will involve disentangling the contribution of social constructs, such as race, socioeconomic status, and culture, from that of the physical environment and genetic susceptibility. One approach to reducing asthma disparities is through the traditional disease prevention stages of intervention. As such, primary prevention targets reductions in asthma incidence; secondary prevention is the mitigation of established disease and involves disease detection, management, and control; and tertiary prevention is the reduction of complications caused by severe disease. Once causative factors at each level of disease prevention are understood, this knowledge can be translated into clinical practice and public health policy.     

Preventing chronic disease and improving health: Broadening the scope of behavioral medicine research and practice

There hasbeen much progress made over thepast 50 yearsindeveloping andapplying the behavioral medicine evidence base to improve the health of individuals and populations. In particular, there has been progress made in applying behavioral and social science research and theories to the challenge of promoting health and disease prevention. These gains not with standing, not all sections of the population have benefited equally, either within or between countries. The disparities in social, mental, and physical health between the most advantaged and the most disadvantaged population groups are in the main, as great as, if not greater, than ever. This represents a tremendous challenge to all of us as behavioral medicine practitioners, teachers, and researchers. Although understanding more about the so-called upstream determinants of health that generate such health disparities is clearly very important, this knowledge will only make a difference if it is used to generate appropriate multilevel intervention strategies over a long and sustained period of time. However, such outcomes will also be affected by diverse aspects of the global natural ecological environment, and by striving for what has been described as a health-sustaining environment. With the increasing impactof globalization on most aspects of our lives, including health, it is important to consider the implications of this for preventing disease and promoting health across traditional national borders. This should challenge us to think about the importance of appropriate dissemination and diffusion of effective interventions at an institutional or policy level not only within a single country, but also between countries. Given the rapid economic and social changes occurring globally, and the tremendous impactof global environmental change on health, there isa need to broaden the scope and practice of behavioral medicine. Irmela Florin Memorial Lecture delivered at 6th International Congress of Behavioral Medicine, Brisbane, Australia (15–18 November, 2000). In recognition of her academic scholarship and leadership within the International Society of Behavioral Medicine, the ISBM president-elect’s address at the Opening Ceremony of each International Congress of Behavioral Medicine is called the Irmela Florin Memorial Lecture.     

Learning from success and failure in psychosocial intervention: an evaluation of low birth weight prevention trials

The object of the study was to evaluate the research designs of social support interventions for prevention of low birth weight (LBW). A literature search of published articles identified 12 randomized controlled trials of social support to prevent LBW birth. These were evaluated using specific methodological criteria for effective intervention research. Only one study showed a significant reduction in LBW. However, none of the studies met all of the proposed criteria for rigorous intervention research. It is premature to conclude that social support interventions are ineffective in preventing LBW. Specific recommendations for future intervention research design are outlined.     

Prevention of psychopathology with early interventions

Early interventions aiming at prevention from future psychopathology are critically evaluated. These interventions include: genetic psychiatric counselling, family planning, improvement of the physical health of the population, prenatal care, intervention in childhood, improvement of the physical health of the child, improvement of the home environment and improvement of the school environment. Although concrete evidence about the effectiveness of many of the above methods is lacking, they are nevertheless worth applying because on an individual basis they often contribute to the alleviation of human suffering. It is pointed out that early preventive interventions are particularly indicated in predisposed individuals (e.g. persons with hereditary predisposition for schizophrenia who must be protected from perinatal complications in order to be prevented from future development of this illness) or high-risk groups (e.g. the siblings of 'battered' children who have a greater probability of being abused by their parents, or 'battered' children who, when becoming parents, have a raised probability of abusing their own children).     

Improving low health literacy and patient engagement: A social ecological approach

ObjectiveThis article posits four principal objectives related to the overarching goal of broadening the conceptualization of health literacy. We propose a social ecological approach to health literacy and patient engagement by illustrating how this multilevel approach offers an array of strategic options for interventions.DiscussionA social ecological approach supports a broader understanding of health literacy that aligns with increased patient engagement. The ecological model highlights the importance of context, demonstrates how health literacy and patient engagement are inextricably connected, and gives rise to strategies to enhance them both. We illustrate the five multilevel intervention strategies for addressing low health literacy and promoting patient engagement: accumulation, amplification, facilitation, cascade, and convergence strategies. In addition, we provide a theoretical foundation to facilitate the development of interventions to enhance health literacy and ultimately increase patient engagement.ConclusionsThe practice implications of adopting a broader social ecological perspective to address low health literacy shifts the field from thinking about individual educational interventions to how individual interventions may be augmented or supported by interventions at additional levels of influence. The potential benefit of adopting a multilevel intervention approach is that combining interventions could produce synergies that are greater than interventions that only utilize one level of influence.     

Efficacy of implantable cardioverter-defibrillators for the prevention of sudden death in patients with hypertrophic cardiomyopathy

BACKGROUND: Hypertrophic cardiomyopathy is a genetic disease associated with a risk of ventricular tachyarrhythmias and sudden death, especially in young patients. METHODS: We conducted a retrospective multicenter study of the efficacy of implantable cardioverter-defibrillators in preventing sudden death in 128 patients with hypertrophic cardiomyopathy who were judged to be at high risk for sudden death. RESULTS: At the time of the implantation of the defibrillator, the patients were 8 to 82 years old (mean [+/-SD], 40+/-16), and 69 patients (54 percent) were less than 41 years old. The average follow-up period was 3.1 years. Defibrillators were activated appropriately in 29 patients (23 percent), by providing defibrillation shocks or antitachycardia pacing, with the restoration of sinus rhythm; the average age at the time of the intervention was 41 years. The rate of appropriate defibrillator discharge was 7 percent per year. A total of 32 patients (25 percent) had episodes of inappropriate discharges. In the group of 43 patients who received defibrillators for secondary prevention (after cardiac arrest or sustained ventricular tachycardia), the devices were activated appropriately in 19 patients (11 percent per year). Of 85 patients who had prophylactic implants because of risk factors (i.e., for primary prevention), 10 had appropriate interventions (5 percent per year). The interval between implantation and the first appropriate discharge was highly variable but was substantially prolonged (four to nine years) in six patients. In all 21 patients with stored electrographic data and appropriate interventions, the interventions were triggered by ventricular tachycardia or fibrillation. CONCLUSIONS: Ventricular tachycardia or fibrillation appears to be the principal mechanism of sudden death in patients with hypertrophic cardiomyopathy. In high-risk patients with hypertrophic cardiomyopathy, implantable defibrillators are highly effective in terminating such arrhythmias, indicating that these devices have a role in the primary and secondary prevention of sudden death.     

Prevention of depression in older age

Depression is a common disorder in later life that is associated with increased disability and costs, and negative health outcomes over time. Antidepressant treatments in the form of medications or psychotherapy are available, but a large proportion of those treated fail to respond fully, and relapse or recurrence of symptoms is frequent among those who recover. Hence, successful prevention would avoid these negative outcomes. This paper selectively reviews currently available observational and trial data on the prevention of depression. It initially reviews risk factors associated with depression, and then discusses strategies for primary (including universal, selective and indicated), secondary and tertiary prevention. Currently available evidence suggests that selective and indicated preventive interventions are feasible and initial results look promising. Existing trial data indicate that ongoing antidepressant treatments reduce the risk of relapse and recurrence of symptoms, but benefits may not extend beyond two or three years. At this point in time, no interventions have been shown to reduce the long term complications associated with depression. Mental health professionals will need to work collaboratively to develop primary, secondary and tertiary preventive interventions that are effective at targeting relevant risk factors systematically and that can be easily adopted into clinical practice.     

Added benefits: reduced depressive symptom levels among African-American female adolescents participating in an HIV prevention intervention

Adolescents experience elevated depressive symptoms which health promotion interventions may reduce. This study investigated whether HIV prevention trial participation decreased depressive symptoms among African-American female adolescents. Adolescents (N = 701; M age = 17.6) first received a group-delivered HIV prevention intervention and then either 12 sexual health (intervention condition) or 12 general health (comparison condition) phone counseling contacts over 24 months. ACASI assessments were conducted at baseline, and at 6-, 12-, 18-, and 24-months post-baseline. Linear generalized estimating equations were used to detect percent relative change in depressive symptoms. Participants reported a 2.7 % decrease in depressive symptoms (p = 0.001) at each assessment. Intervention participants endorsed an additional 3.6 % decrease in depressive symptoms (p = 0.058). Trial participation was associated with reduced depressive symptomatology, particularly among those receiving personalized sexual health counseling. HIV prevention interventions may benefit from incorporating additional content to address adolescents’ mental health needs.     

Policy perspectives on public health for Mexican migrants in California

This analysis focuses on public policies that affect primary HIV prevention and access to HIV care for Mexican migrants residing in California. Policy or structural level interventions, as opposed to behavioral or psychologic interventions, help to shape the environment in which people live. We use a conceptual model for policy analysis in public health to understand better the challenges faced by Mexican migrants. We assess potential policy level interventions that may serve as barriers to or facilitators of primary HIV prevention and care for Mexican migrants. Among potential barriers, we discuss restrictions on public health services based on legal immigration status, limits placed on affirmative action in education, and laws limiting travel and immigration. Under potential facilitators, we discuss community and migrant health centers, language access laws, and the use of community-based groups to provide prevention and treatment outreach. We also report on the limited research evaluating the implications of these public policies and ways to organize for more responsive public policies.     

Genetic expression outside the skin: clues to mechanisms of Genotype x Environment interaction

The rapidly moving study of Gene x Environment interaction (G x E) needs interim conceptual tools to track progress, integrate findings, and apply this knowledge to preventive intervention. We define two closely related concepts: the social mediation of the expression of genetic influences and the interaction between the entire genotype and the social environment (G x E). G x E, the primary focus of this report, assesses individual differences in the full genotype using twin, sibling, and adoption designs and, for the most part, employs fine-grained analyses of relational processes in the social environment. In comparison, studies of Allele x Environment interaction assess the influence on development of one or more measured polymorphisms as modified by environmental factors. G x E studies build on work showing how the social environment responds to genetic influences and how genetic influences shape the social environment. Recent G x E research has yielded new insight into variations in the sensitivity of the social environment to genotypic influences and provides clues to the specificity and timing of these environmental responses that can be leveraged to inform preventive interventions aimed at reducing genetic risk for problem behavior.     

Individualised multifactorial lifestyle intervention trial for high-risk cardiovascular patients in primary care.

BACKGROUND: The multiprofessional teams in Finnish health centres are well placed to carry out interventions aimed at the prevention of cardiovascular diseases. AIM: To evaluate the effectiveness of an individually tailored multifactorial lifestyle intervention in primary care for individuals at high risk for cardiovascular disease. DESIGN OF STUDY: A randomised controlled trial was conducted over 24 months with interim assessments at six and 12 months. SETTING: A health centre in Finland with a patient population of 11,000. METHOD: One hundred and fifty adults aged 18 to 65 years old with existing cardiovascular disease or multiple risk factors were randomised to active multiprofessional risk factor intervention or to standard care. The main outcome measure was a change in cardiovascular risk-factor score. Secondary outcomes were changes in blood pressure, weight, body-mass index, serum cholesterol, blood glucose, smoking cessation, and exercise habits. RESULTS: The cardiovascular risk score decreased by 28% in the intervention group (23% in the control group), body weight decreased by 3.7% (2%) and total cholesterol decreased by 10.8% (6.5%), while time engaged in exercise increased by 39% (43%). Differences were not significant. CONCLUSIONS: Cardiovascular risk levels of high-risk individuals decreased in both intervention and control groups. Primary care prevention should be targeted to high-risk persons. Long-term follow-up studies are needed.     

The delivery of prevention programmes for cardiovascular disease and chronic obstructive pulmonary disease in Lodz by primary care physicians

Introduction

In Poland, the National Health Fund (NHF) has contracted preventative interventions in primary health care (PHC) delivered by family physicians, internists, paediatricians and other physicians. The aim of the study was determining whether there is a correlation between PHC physicians’ specialisation and the rate of interventions delivered for the prevention of cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD).

Material and methods

A retrospective observational study of the NHF 2005 data related to the delivery of prevention programmes using Spearman''s rank correlation coefficient (rho).

Results

Out of 133 PHC providers in Lodz, 25 participated in the cardiovascular disease (CVD) prevention programme, 22 in the chronic obstructive pulmonary disease (COPD) prevention programme at a basic level, and 20 at an extended level (with contract completion rates respectively of 55.2, 47.8 and 51.5%). When all three prevention programmes were analysed together, the correlation between the rate of preventative interventions by physicians with a particular specialisation and the contract completion rate was positive (rho > 0) only for family physicians.

Conclusions

Participation of primary health care providers in preventative programmes and the rates of their delivery of interventions were low despite additional funding. The correlation between the proportion of physicians with a particular specialisation, involved in CVD and COPD prevention interventions delivery, and the rate of the programme accomplishment was the strongest for family physicians.     

Designing effective HIV/AIDS social and behavioral interventions for the population of those age 50 and older

Social and behavioral HIV/AIDS prevention interventions designed to test their effects on older cohorts are sorely lacking in the scientific literature even though middle-aged and older people represent a significant minority of both existing and new AIDS cases. This article raises key issues relevant in developing and evaluating HIV/AIDS social and behavioral interventions for older cohorts. These interventions must build on our current understanding of behavior change and HIV prevention successes with younger populations while considering important intervention principles gathered from work with older populations in other health arenas. In addition, the authors expand on recent national panels and published reviews relevant to the topic and provide a set of intervention recommendations for use in tandem with these intervention principles. The article also calls for additional research into the sociocultural contexts that influence risk-taking among older cohorts and for the development of interventions at multiple levels. Pragmatic considerations such as identifying and dismantling ageism in interventions, delineating intervention outcomes, and planning for intervention transferability, dissemination, and sustainability also are raised.     

Nutrition in the primary and secondary prevention of stroke

Stroke is a worldwide major health issue. As some of the risk factors are modifiable, it is of high importance to understand how we can minimize the risk for stroke. Multifactorial interventions should be provided to patients in the frame of primary and secondary prevention. Obesity is a well-established modifiable factor as well as the dietary pattern that mostly depends on the social environment, the lifestyle and the habits of each individual. So, dietary changes should be part of the holistic approach which includes improvements in the regulation of hypertension, hyperlipidaemia and hyperglycaemia. In the present review, we try to provide a global approach on how diet can influence the risk of stroke and especially the nutritional influence on lipid profile and vessel disease and the role of dietary modification in the secondary stroke prevention. The importance of salt restriction, DASH and Mediterranean diet low in saturated and high in polyunsaturated fats, and the management of obesity seem to be the most important dietary priorities.     

Imagining roles for epigenetics in health promotion research

Discoveries from the Human Genome Project have invigorated discussions of epigenetic effects—modifiable chemical processes that influence DNA’s ability to give instructions to turn gene expression on or off—on health outcomes. We suggest three domains in which new understandings of epigenetics could inform innovations in health promotion research: (1) increase the motivational potency of health communications (e.g., explaining individual differences in health outcomes to interrupt optimistic biases about health exposures); (2) illuminate new approaches to targeted and tailored health promotion interventions (e.g., relapse prevention targeted to epigenetic responses to intervention participation); and (3) inform more sensitive measures of intervention impact, (e.g., replace or augment self-reported adherence). We suggest a three-step process for using epigenetics in health promotion research that emphasizes integrating epigenetic mechanisms into conceptual model development that then informs selection of intervention approaches and outcomes. Lastly, we pose examples of relevant scientific questions worth exploring.     

Toward health status insurance

This paper advances a new concept in health insurance. Health status insurance is a health insurance whose primary aim is to improve health status and decrease inequality in health within the covered population. Redistribution and control of cost is a secondary aim, closely integrated with the health status aim. Health status insurance differs from conventional health insurance in four respects: 1) the health status and health risks of enrollees are assessed and individual plans are developed jointly by the providers and enrollees to raise their health status to a given level; 2) interventions are not limited to the patients, but they extend to the patients' physical and social environments; 3) supplementary income or help in organizing are provided to enrollees who do not have an income sufficient to maintain their health or who need help to overcome local environmental situations adverse to their health, respectively; and, 4) the health status insurance organization actively champions national policies to change the social environment for the improvement of health. The concept of health status insurance is applicable to national health insurance systems, large private health insurance systems, or, national health service (when the responsible governmental agency becomes the health status insurer). Three modalities of implementation are presented. The readiness of society and governments to adopt health status insurance is discussed from a historical perspective.     

成都市成华区2017年碘缺乏病防治 健康教育干预措施效果评价

目的 通过调查成都市成华区居民碘缺乏病防治知识知晓率情况,评估碘缺乏病健康教育效果,为今后的防治工作提供科学依据。方法 在成华区选择3个街道办,在每个街道办分别选择一所项目学校和一个代表社区,选择30名5年级小学生及15名家庭妇女。结合主题日宣传、社区、学校综合干预措施在全区开展健康教育,对比干预前后小学生及家庭妇女碘缺乏病防治相关知识知晓率。结果 干预前家庭妇女的知识知晓率低于小学生（67.41% vs 82.22%）,差异具有统计学意义（P＜0.05）。通过在社区、学校等场所开展系列健康教育活动,利用主题日开展宣传,干预后小学生碘缺乏病防治知识知晓率为98.15%,家庭妇女知晓率为95.56%,均较干预前有所提高,差异具有统计学意义（P＜0.05）。健康教育前碘缺乏病防治知识知晓率较低的辖区学生及家庭妇女知识知晓率的提升更为明显。结论 健康教育干预措施能够有效提高小学生、家庭妇女人群碘缺乏病防治知识知晓率,增强群众的健康意识。     

Behavioral research in HIV/AIDS primary and secondary prevention: recent advances and future directions

Great advances have been made over the past decade in behavioral research on how to help persons avoid contracting HIV infections (primary prevention) and how to reduce or alleviate adverse consequences among persons who are living with HIV disease (secondary prevention). Within the primary prevention areas, research has shown the effectiveness of risk-reduction interventions undertaken with individuals, couples, small groups, communities, and at a social policy/structural level. Advances in HIV medical care have also created important new challenges and roles for behavioral scientists in the area of HIV secondary prevention. This article concludes by identifying key emerging issues in HIV behavioral research that will require attention in the years ahead.     

The Canadian asthma primary prevention study: outcomes at 2 years of age

BACKGROUND: Avoidance of individual risk factors have not been successful in preventing the development of asthma. OBJECTIVE: We sought to determine the effectiveness of a multifaceted intervention program in primary prevention of asthma in high-risk infants. METHODS: We identified 545 high-risk infants on the basis of an immediate family history of asthma. Families were randomized into intervention or control groups. Intervention measures included avoidance of house dust mite, pet allergen, and environmental tobacco smoke. Breast-feeding was encouraged with formula supplementation if necessary, and introduction of solid foods was delayed. RESULTS: At 2 years of age, 19.5% of the children had asthma, and 14.7% had atopy (positive skin test response to one or more common allergens). Significantly fewer children had asthma in the intervention group compared with in the control group (16.3% vs 23.0%), with 60% less persistent asthma at 2 years. There was a 90% reduction for recurrent wheeze in the intervention group compared with that seen in the control group. Exposure to maternal environmental tobacco smoke during pregnancy or the first year was a risk factor for asthma at 2 years of age. A positive skin test response, particularly to food, at 12 months predicted asthma at 2 years. There was no significant difference for atopy between the intervention and control groups, but daycare reduced atopy at 2 years. CONCLUSION: This multifaceted intervention program during a window of opportunity in the first year of life was effective in preventing asthma in high-risk children at 2 years of age. Future studies with this cohort at school age are important.